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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide5.html
October 01, 2022 - Preventing Hospital-Associated Venous Thromboembolism
Chapter 5. Implement the VTE Prevention Protocol
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
Chapter 2. Analyze Care De…
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - In Conversation with...Sorrel King
March 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sorrel King. PSNet [internet]. 2007.In Conversation with...Sorrel King. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to
getting involved in safety an…
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Undetected Foreign Object
Citation Text:
Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Delayed Recognition of a Positive Blood Culture
Citation Text:
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
January 01, 2024 - Final Progress Report: How Do Consumers View the Risks of Medical Errors?
FINAL REPORT
Title of Project: How Do Consumers View the Risks
of Medical Errors?
Principal Investigator: Ellen Peters
Team Member: Paul Slovic
Organization: Decision Research
Inclusive Dates of Project: 09/01/2001 – 08/31/2003
Federal …
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency
Citation Text:
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
June 03, 2008 - Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement
Transforming the Morbidity and Mortality Conference
into an Instrument for Systemwide Improvement
Jamie N. Deis, MD; Keegan M. Smith, MD; Michael D. Warren, MD;
Patricia G. Throop, BSN, CPHQ; Gerald B. Hickson, MD; …
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www.ahrq.gov/sites/default/files/2025-03/newman-toker-report.pdf
January 01, 2025 - Final Progress Report: A Multiyear Grant To Support the Diagnostic Error in Medicine (DEM) Annual Conference
FINAL PROGRESS REPORT TITLE PAGE (R13HS019252, PI Newman-Toker)
Title: A Multiyear Grant to Support the Diagnostic Error in Medicine (DEM) Annual Conference
Principal Investigator: David E. Newman-Toker
Tea…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
January 01, 2025 - Table of Contents: Volume 1. Assessment
Contents
Volume 1. Assessment
Prologue: Laying the Foundation
Kerm Henriksen
Looking Forward, Benefiting from the Past
Envisioning Patient Safety in the Year 2025: Eight Perspectives
Kerm Henriksen, Caitlin Oppenheimer, Lucian Leape, et al.
What Exactly Is Patien…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 3 Tools
3A: Pressure Ulcer Prevention Pathway for Acute Care
3B: Elements of a Comprehensive Skin Assessment
3C: Pressure Ulcer Identification Notepad
3D: The Braden Scale for Predicting Pressure Sore Risk
3E: Norton Scale
3F: Care Plan
3G: Pat…
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride
Extravasation.
April 26, 2023
The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
The Case
A 52-year-old man with a history of lymphoplasmacytic lymph…
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www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
December 01, 2012 - Facilitator Notes
CUSP Toolkit, Apply CUSP
The Apply CUSP module of the CUSP Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit, including TeamSTEPPS®…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-obhemorrhage.html
July 01, 2023 - Labor and Delivery Unit Safety: Obstetric Hemorrhage
AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements related to the management obstetric hemorrhage. The key elements are presented within the framework of the Comprehensive Unit-base…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
January 01, 2025 - Table of Contents: Volume 4. Technology and Medication Safety
Contents
Volume 4. Technology and Medication Safety
Prologue: Technology and Medication Safety
Mary L. Grady
Health Information Technology
“Safeware”: Safety-Critical Computing and Health Care Information Technology
Robert L. Wears, Nancy G. Lev…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/social-needs-tool.pdf
May 01, 2021 - IDENTIFYING AND ADDRESSING SOCIAL NEEDS IN PRIMARY CARE SETTINGS
NATIONAL CENTER
FOR EXCELLENCE IN
PRIMARY CARE RESEARCH
1
IDENTIFYING AND ADDRESSING
SOCIAL NEEDS IN PRIMARY CARE SETTINGS
Should our primary care practice screen for social needs?
Social determinants of health (SDOH) are widely r…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Improving Antibiotic Use Is a Patient Safety Issue
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Improving Antibiotic Use Is a Patient Safety Issue
Long-Term Care
SAY:
Welcome to this presentation titled “Improving Antibiotic Use Is a Patie…